For many individuals, tinnitus is a very disturbing condition that can influence one's daily activities, relationships, and well-being. As audiologists, we encounter these patients on a regular basis; however, many of us miss the opportunity to help them and grow our practice at the same time. The audiological tinnitus evaluation test battery, the application of appropriate tinnitus assessment tools, as well as a variety of scientifically supported and evidence-based tinnitus management strategies, such as counseling, sound therapy, cognitive behavioral therapy, and alternative treatments are discussed in this article.
HISTORY AND PATHOLOGY
For thousands of years, humans have been struggling to cure tinnitus—and this battle may continue for many decades to come. Records in old medical texts cite tinnitus pathology and management, such as Ebers Papyrus from ancient Egypt, Pliny the Elder (23-79 AD), and the work of the Persian physician Avicenna (980-1036) in his book Canon.1 Explaining the history of tinnitus and advancements in managing this condition is always a good strategy for counseling patients with tinnitus.
Tinnitus is a brain phenomenon that can be generated by a variety of factors and disorders, which most audiologists are completely familiar with. However, its origination is still under debate. From a neuroscience point of view, it seems that factors such as central gain and cross-modal compensations in subcortical structures may contribute to tinnitus and its generation.2,3 Furthermore, research literature indicates some electrophysiological findings that confirm the notion that pre-attentive and automatic central auditory processing are compromised in those with chronic tinnitus.4
EVALUATION AND ASSESSMENT
Tinnitus History and Questionnaires. Tinnitus evaluation usually starts with a comprehensive case history interview. The patient is then given a set of questionnaires for the clinician to get a better understanding of the extent of the patient's tinnitus disturbance and the role of hearing loss. These questionnaires include the Tinnitus Handicap Inventory (THI),5 Tinnitus Reaction Questionnaire (TRQ),6 Tinnitus Functional Index (TFI),7 and Tinnitus and Hearing Survey (THS).8 I routinely use TRQ because it includes a question on suicidal thoughts—an important aspect that audiologists need to be aware of. The THS is also important due to its recognition of hearing difficulties as a major contributor to tinnitus annoyance.
Other factors, such as anxiety, depression, and stress, should also be checked. The mental health of tinnitus patients as well as the mental health of their parents have been shown to be important factors when evaluating patients with tinnitus. One of my research collaborators, Hashir Aazh, PhD, and his colleagues have found significant interactions between parental mental health and the level of tinnitus handicap in adults.9-11
Psychoacoustical Tinnitus Assessment. Tinnitus assessment is a recognized CPT procedure under the code 92625. It comprises assessment of tinnitus pitch and loudness, minimal masking level, and residual inhibition (optional). Many clinical guidelines are available for tinnitus assessment; consider the work of Henry, et al.12
Many clinicians may not know the purpose and benefits of performing a tinnitus assessment. I believe it is an important part of a tinnitus visit, and I use the assessment data in my counseling sessions. For example, knowing the tinnitus pitch is important because if the tinnitus is associated with hearing loss, adjusting the hearing aids around the tinnitus pitch or providing a band of sound around that frequency is usually helpful in tinnitus sound therapy. It is also helpful in generating appropriate signals using digital and wearable sound generators. Data on tinnitus loudness can be a useful counseling tool. I usually share the following with a patient at the start of a counseling session: Tinnitus patients can be divided into three groups. Out of the 50 million people who have reported tinnitus in the United States, 35 million of them do not really care about the sound, and, if you measure their tinnitus loudness, it is less than 10 dB SL. The second group includes about 13 million people who find tinnitus annoying and disturbing, which somewhat influences their life; tinnitus loudness in this group is also below 10 dB SL. The remaining two million tinnitus patients are those who are extremely annoyed by it and usually fear that they will lose their jobs and relationships. Then I would ask the patient, “So what do you think the tinnitus loudness is for the third group?” Many patients would respond, “Is it also 10 dB SL?” Patients are always surprised when I give them their data, which show their tinnitus loudness at around 10 dB SL. In the hundreds of tinnitus patients that I have seen, I rarely encountered one with greater than 10 dB tinnitus loudness percept.
Another piece of useful information from tinnitus assessment is the result of the residual inhibition (RI) test. RI is the suppression of tinnitus for a short (or long in some cases) time (seconds to minutes) following the introduction of a masking sound for one minute. Several physiological studies have provided evidence of neural suppression of spontaneous activities during RI13,14 and its repeatability.15 I prefer to use narrowband noise (NBN) around the center frequency of tonal tinnitus to perform an RI evaluation. For many patients, experiencing this suppression of their tinnitus provides hope since they realize that there are ways to manipulate tinnitus loudness.
MANAGEMENT PROTOCOLS, METHODS
Many options are available for tinnitus management—some are effective, some are not. As clinicians, we are encouraged and somewhat obligated to use methods that are ethically feasible and evidenced-based (i.e., supported by research). Just a few years ago, an outstanding clinical practice guideline (CPG) for tinnitus was published.16 This CPG recommended targeted history and physical examination, comprehensive audiological examination, patient education and counseling, hearing aid evaluation (for those with tinnitus and hearing loss), and cognitive behavioral therapy (CBT). It also recommended sound therapy for those with persistent and bothersome tinnitus. The evidence-based guidelines did not support other types of tinnitus management approaches such as the use of medications, supplements, and transcranial magnetic stimulation.16
Sound Therapy and Counseling. This approach has possibly been practiced for hundreds of years. It has been shown that tinnitus can be drowned by other sounds. Historical evidence shows that patients were told to walk by the sea or listen to the streams and creeks to not hear their tinnitus. In the modern world, sound therapy has been accomplished using hearing aids, sound generators, modified musical tracks, among others.17 Interestingly, research literature shows that when patients listen to a prolonged low-level noise, neuroplastic changes occur in the brain, which helps reduce tinnitus percept.18,19
Martin Pinekowski, PhD, introduced a variety of sound therapy stimuli from various scientists and laboratories. These include broadband noise (BBN), filtered BBN combined with music, NBN, music notch-filtered around the tinnitus pitch, and tones combined with electrical stimulations.20
Evidence also shows that the tinnitus experienced by many patients is actually related to their hearing loss. Comprehensive counseling and hearing aid use have been shown to be very effective in managing tinnitus.21
At least three common methods of tinnitus management combine sound therapy and counseling techniques, namely: Tinnitus Activities Treatment (TAT), which involves counseling the whole person;22 Tinnitus Retraining Therapy (TRT), which targets habituation to the reactions evoked by tinnitus;23 and Progressive Tinnitus Management (PTM), which teaches coping skills to reduce functional distress.24
These methods may suggest total or partial masking of tinnitus and mixing point in tinnitus sound therapy. For many clinicians, it can be confusing to determine the most effective method. This dilemma was finally resolved by researchers who found no clinically significant difference between total and partial tinnitus masking.25
Recently, Tyler and colleagues also looked at sound therapy with partial masking alone, in the absence of tinnitus education counseling, to allow for better control. The study was limited, using one patient as its control design and a small sample size of 15 subjects. However, sound therapy proved beneficial to 33 percent of participants, indicating that sound therapy alone can be a useful tool in treating tinnitus.26
Sound therapy-based treatments such as Neuromonics, Desyncra, and the Levo System employ acoustic stimuli to help patients with bothersome tinnitus. Combining these methods with counseling can be beneficial.
Cognitive Behavioral Therapy (CBT). CBT has been shown to be one of the most effective tinnitus management methods. CBT for tinnitus is designed to identify negative automatic thoughts (NATs) and examine the validity and truth behind those negative thoughts. After a few sessions, patients realize that most of these NATs, such as fear, sleep disorders, or poor relationships, are false perceptions. Many European audiology clinics offer CBT to tinnitus patients, and patients have shown positive improvements based on self-report assessments of the handicap caused by tinnitus.27 CBT is the most evidence-based method for tinnitus management.28
Alternative Therapies. Other modes of management and treatment have been examined. One of the most recent methods employs bimodal stimulations. Bimodal auditory-somatosensory stimulation introduces auditory signals while the patient is receiving low-level electrical pulses. This type of therapy for suppressing chronic tinnitus induces long-term depression (LTD) that weakens the connections between neurons.29
The education and knowledge of clinicians, along with their care and empathy for patients, play important roles in tinnitus management. Numerous workshops and continuing education opportunities are available for clinicians to learn more about tinnitus. My hope is that the American Academy of Audiology will offer a specialty in tinnitus like the ones available for pediatric audiology and cochlear implants. Counseling and patient education are extremely important components of tinnitus management in audiology practices. The recommendations of a recent paper by Henry and Manning indicate that an efficient diagnostic/procedural protocol regarding case history, referral, assessment, counseling, treatment, and follow-up services would help promote the standardization of tinnitus therapy approaches and allow for a more effective, evidence-based procedure.30 Finally, I agree with and like the way that Chris Spankovich, AuD, PhD, MPH,31 who described a tinnitus management plan: “It is you as the provider that makes the difference.”
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